Oral Anticoagulants

Question 1

Coumadin (warfarin) MOA

Answer 1

Inhibitors VKOR complex to reduce Vit K available for SNOT, protein C and protein S

Question 2

S-warfarin has problem with

Answer 2

2C9

Question 3

R warfarin has problems with:

Answer 3

1A2 > 3A4 > 2C19

Question 4

Warfarin dosing

Answer 4

Initiated 5 mg daily with possible LD of 10 mg x 2 days before maintenance regimen

Question 5

Use 2.5 mg of warfarin if:

Answer 5

Greater than 75 y.o.
Liver or renal disease
HF
High bleed risk
Concurrent therapy
Acute EtOH intake
Smoking cessation
Poor nutritional status
Infection
Malignancy

Question 6

Testing for 2C9 and VKORC1 =

Answer 6

Not recommended!!

Question 7

Increased warfarin efficacy or bleeding:

Answer 7

Amiodarone
Fluconazole
Metronidazole
NSAIDs
Bactrim
Herbals with "G"
Other anticoagulants

Question 8

Decreasing warfarin efficacy:

Answer 8

Rifampin
St. John’s Wort
Carbamazepine

Question 9

Normal INR

Answer 9

~1

Question 10

Afib

VTE treatment/prevention

Answer 10

2-3

Question 11

Triple therapy (ASA + P2Y12 inhibitor + warfarin) INR

Answer 11

2-2.5 + GI prophylaxis

Question 12

Less than 1.5

Answer 12

Increase total weekly dose 10-20%

Question 13

1.5-1.9

Answer 13

Increased total weekly dose 5-15%

Question 14

2-3

Answer 14

Continue

Question 15

3.1-3.5

Answer 15

Decrease total weekly dose 5-15%

Question 16

3.6-4.4

Answer 16

Decrease total weekly dose 10-20% and hold for 1-2 doses

Question 17

Yes signs/symptoms of major bleed, treat with:

Answer 17

Vit K 10 mg IV + FFP 15-30 mL/kg OR PCC (preferred)

Question 18

No signs/symptoms of major bleed + 4.5-10, treat with

Answer 18

Hold 1-2 doses
Recheck INR in 2-3 days
Minor bleed or risk of bleeding: Vit K 1-2.5 mg PO

Question 19

No signs/symptoms of major bleed greater than or equal to 10, treat with

Answer 19

Vit K 2.5-5mg PO

Hold Coumadin

Question 20

Fresh Frozen Plasma (FFP)

Answer 20

Immediate reversal, may lead to volume overload

Question 21

Vit K1

Answer 21

12-24 hr peak effect, large doses may result in resistance

Question 22

Prothrombin Complex Concentration (PCC)

Answer 22

Immediate reversal
Expensive
Wears off after ~6-8 hours

Question 23

Initiation outpatient followup

Answer 23

Recheck in 5-7 days

Question 24

Out of range less than 4.5 or 1 INR in range followup

Answer 24

1-2 weeks

Question 25

Greater than or equal to 2 INRs within range

Answer 25

4 -12 weeks

Question 26

Severe bleeding (hospitalized) INR followup

Answer 26

PRN until bleeding stops

Question 27

INR greater than 10 followup

Answer 27

1-2 days

Question 28

INR 4.5-10 followup

Answer 28

2-3 days

Question 29

Warfarin in the hospital

Answer 29

``` Obtain baseline INR Evaluate current interactions Counsel on importance of monitoring, compliance, drug-food interactions, ADRs Monitor INR on regular basis Titrate ```

Question 30

Bridging therapy is used:

Answer 30

VTE Severe thrombophilia Afib Valve replacement

Question 31

Bridge therapy =

Answer 31

warfarin and parenteral on day 1 of hospitalization

Question 32

Continue IV heparin or SQ low-molecular weight heparin until:

Answer 32

Warfarin use for at least 5 days | Two INRs above 2.0, 24 hours apart

Question 33

Pradaxa (dabigatran) DVT/PE Dosing

Answer 33

150 mg PO BID with 5-10 days of IV anticoag first | Less than or equal to 30 CrCl = do not use

Question 34

Pradaxa (dabigatran) Non-valvular Afib Dosing

Answer 34

150 mg PO BID | CrCl 15-30: 75 mg PO BID

Question 35

Pradaxa (dabigatran) MOA

Answer 35

Direct thrombin inhibitor

Question 36

Xarelto (rivaroxaban) MOA

Answer 36

Factor Xa inhibitor

Question 37

Xarelto (rivaroxaban) Acute DVT/PE Dosing

Answer 37

15 mg PO BID x 21 days then 20 mg PO daily | Don't use if CrCl is less than 30

Question 38

Xarelto (rivaroxaban) Nonvalvular afib dosing

Answer 38

20 mg PO daily CrCl 15-50 : 15 mg PO daily Less than 15 do not use

Question 39

Xarelto (rivaroxaban) Hip/knee DVT thromboprophylaxis dosing

Answer 39

10 mg PO daily up to 35 days | Don't use if CrCl is less than 30

Question 40

Eliquis (apixaban) MOA

Answer 40

Factor Xa inhibitor

Question 41

Eliquis (apixaban) Acute DVT/PE Dosing

Answer 41

10 mg PO BID x 7 days then 5 mg PO BID | SCr greater than 2.5 or CrCl less than 25 don't use

Question 42

Eliquis (apixaban) Nonvalvular Afib dosing

Answer 42

5 mg PO BID | Do not use if CrCl is less than 25

Question 43

Eliquis (apixaban) Nonvalvular Afib dosing Adjust

Answer 43

Adjust to 2.5 mg PO BID if two of the following (Scr greater than 1.5, greater than 80 yo, less than 60 kg)

Question 44

Eliquis (apixaban) Hip/Knee DVT thromboprophylaxis dosing

Answer 44

2.5 mg PO BID | Do not use if CrCl less than 30

Question 45

Savaysa (edoxaban) MOA

Answer 45

Factor Xa inhibitor

Question 46

Savaysa (edoxaban) Acute DVT/PE Dosing

Answer 46

60 mg PO daily with 5-10 days of IV anticoag | If less than 60 kg use 30 mg PO daily

Question 47

Savaysa (edoxaban)Acute DVT/PE Dosing Adjust

Answer 47

15-50 CrCl use 30 mg PO daily | Don't use if less than 15

Question 48

Savaysa (edoxaban) Nonvalvular Afib Dosing

Answer 48

60 mg PO daily

Question 49

Savaysa (edoxaban) Nonvalvular Afib Dosing Adjust

Answer 49

Greater than 95 do not use 15-50 use 30 mg PO daily Less than 15 do not use

Question 50

Pros to Oral Anticoagulants

Answer 50

Lower bleeding risk than warfarin No regular lab monitoring Consistent dosing Less interactions

Question 51

Cons to Oral Anticoagulants

Answer 51

No reversal agent Pradaxa- dialysis Others - activated prothrombin complex concentration Not good for renal impairment or dialysis pts Specific dosing can be confusing